Development of Clinical Pharmacy Services in China
by Jonathan Penm
Jonathan Penm is the Vice President (Western Pacific) of the Hospital Pharmacy Section of the International Pharmaceutical Federation (FIP) and the Chair of the New South Wales Branch of the Society of Hospital Pharmacists of Australia (SHPA). He works as a clinical pharmacist at Sydney Hospital and Sydney Eye Hospital and is also completing his PhD at the Faculty of Pharmacy, University of Sydney. Jonathan’s thesis centres on hospital pharmacists' influence on prescribing in the Western Pacific Region, which consists of 37 nations. His enthusiasm for hospital pharmacy has also been recognized as he has been awarded the FIP Young Pharmacist Grant for Professional Innovation in 2010 and the Young Alumni Award for Achievement from the Faculty of Pharmacy, University of Sydney in 2012.
|It is estimated that 90% of public hospitals’ revenue is currently generated directly from patients for medications and tests.3,4|
Recently, China initiated an ambitious healthcare reform aiming to provide affordable and equitable basic health care to all by 2020.1 This reform focuses on public hospitals, which deliver more than 90% of China’s inpatient and outpatient services.2 The public hospital sector has received limited government funds since the economic reform in 1985. It is estimated that 90% of public hospitals’ revenue is currently generated directly from patients for medications and tests.3,4 Furthermore, medications alone account for over 50% of this revenue.1,5 This has led to a perception of inappropriate prescribing. Reynolds and McKee (2009) claimed two forms of financial incentives to prescribe existed in China; ‘One was created by pharmaceutical companies, who sometimes arrange to split profits with prescribers, illegally and covertly, while the other emanated from all health providers, which are entitled to make a 15% profit on sales to fund services.’6 As a result, over-prescribing has become a concern in the context of China’s increasing healthcare expenditure.1
To meet the goals of the healthcare reform, and change the way health is delivered and paid for in China, new policies issued by China’s Ministry of Health (MoH) surrounding the accreditation of tertiary hospitals7 and antimicrobial use in hospitals8 mandate clinical pharmacy services be integrated into China’s hospitals. Internationally, the development of clinical pharmacy services has expanded the role of a pharmacist from the traditional product-focused role to a patient-focused one.9,10 This new role aims to provide patient-focused care and promote high quality and rational use of medications.
China’s MoH conducted a pilot program to introduce clinical pharmacists in 50 hospitals from 2005-2008.11 At the conclusion of this pilot, nearly all directors’ of hospitals, doctors, patients and pharmacy directors surveyed (n=207) supported the role of clinical pharmacists.12 As a result, in 2011 the MoH issued a policy that all secondary and tertiary hospitals should have three and five full-time clinical pharmacists respectively.13
Antimicrobial stewardship has provided a platform for facilitating clinical pharmacy services in China, as antimicrobial resistance is of major concern.14,15 From 1999-2001, the prevalence of resistance amongst hospital-acquired staphylococcus aureus infections was 77%,14 and streptococcus pneumonia over 80%15 and is on the rise.8 Accordingly, the MoH released a series of campaigns and policies8,16 stating that all secondary and tertiary hospitals should have clinical pharmacists trained in infectious diseases. Furthermore, these trained pharmacists must be able to give guidance and approval for restricted antimicrobial use.8 This highlights the important contribution clinical pharmacy services have on antimicrobial stewardship as per international practices.17
Research led by the University of Sydney has highlighted the importance of policies and administrative support, which appear crucial for the successful implementation of clinical pharmacy services, particularly to off-set the financial incentives gained from inappropriate prescribing.18 The Basel Statements (2008), developed by the International Pharmaceutical Federation (FIP) Hospital Pharmacy Section, are consensus statements reflecting the profession’s preferred vision for hospital pharmacy practice around the world. These statements support both developed and developing countries in strategically framing clinical pharmacy services in hospitals.9-21
|China is well on the way to changing the health landscape, and it is recognised that pharmacists plan an integral role. We did, however, identify that many barriers to change exist, such as the financial incentives prescribers receive, education, training and evaluation of the clinical pharmacists.18|
We utilised these statements to develop an interview guide and interviewed over 100 pharmacists and hospital administrators about their practice. China is well on the way to changing the health landscape, and it is recognised that pharmacists plan an integral role. We did, however, identify that many barriers to change exist, such as the financial incentives prescribers receive, education, training and evaluation of the clinical pharmacists.18 Furthermore, ensuring clinical pharmacists are adequately trained is a challenge in China, and will require more time. By the end of 2011, China was reported to have 1399 tertiary and 6468 secondary hospitals,22 which will require at least 26,399 clinical pharmacists to meet the policy requirements of the MoH.13 With only 15 clinical pharmacists graduating from one of the country’s largest courses in 20074,5 and new courses only introduced recently, a focus on educating pharmacists and pharmacy support staff seems vital. It therefore seems inevitable that there will be a large lag time before these MoH goals are reached and clinical pharmacy services are a routine part of hospital systems.
We strongly recommend that the Basel Statements continue to be used to assess clinical pharmacy services in China as they are internationally recognised, regardless of the level of clinical pharmacy services provided or the country in which they are being implemented.
Clinical pharmacists in China have expressed a great need to assess their contribution to the hospital. Having such a system will ensure all departments in the hospital have the same expectations and will allow individual pharmacists to focus their efforts on the essential elements of clinical pharmacy services.
2 China health undertakings statistical bulletin, 2011. Ministry of Health of the People’s Republic of China. at http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohwsbwstjxxzx/s7967/201204/54532.htm. (Accessed 20/08/2012)
3 Alcorn T, Bao B. China progresses with health reform but challenges remain.[Erratum appears in Lancet. 2011 Jul 9;378(9786):128]. Lancet 2011;377:1557-1558.
4 Hsiao WC. When incentives and professionalism collide. Health Aff 2008;27:949-951.
5 Chinese doctors are under threat. Lancet 2010;376:657.
6 Reynolds L, McKee M. Factors influencing antibiotic prescribing in China: an exploratory analysis. Health Policy 2009;90:32-36.
7 National accreditation criteria for tertiary hospitals. Ministry of Health of the People's Republic of China, 2011. at http://www.moh.gov.cn/mohylfwjgs/s3577/201112/53721.shtml. (Accessed March 3, 2013)
8 Policy on the clinical use of antimicrobials. Ministry of Health of the People's Republic of China, 2011. at http://www.moh.gov.cn/mohyzs/s3584/201205/54645.shtml. (Accessed March 3, 2013)
9 Nissen L. Current status of pharmacist influences on prescribing of medicines. Am J Health Syst Pharm 2009;66:S29-34.
10 Anderson S. The state of the world's pharmacy: a portrait of the pharmacy profession. Journal of Interprofessional Care 2002;16:391-404.
11 Implementing the pilot program to build the system for clinical pharmacists. Division of Medical Affairs, Ministry of Health of the People's Republic of China, 2007. at http://www.moh.gov.cn/mohyzs/s3577/200804/18775.shtml. (Accessed March 3, 2013)
12 Summary report for clinical pharmacist pilot training project. Committee for pharmacy administration, Chinese hospital association, 2009. at http://www.chinadtc.org.cn/index.php?option=com_content&module=53&sortid=&artid=408&menuid=72. (Accessed March 3, 2013)
13 Policy on pharmacy administration in health care facilities. Ministry of Health of the People's Republic of China, 2011. at http://www.moh.gov.cn/mohyzs/s3585/201103/51113.shtml. (Accessed March 3, 2013)
14 Zhang R, Eggleston K, Rotimi V, et al. Antibiotic resistance as a global threat: Evidence from China, Kuwait and the United States. Globalization and Health 2006;2.
15 Yao K, Yang Y. Streptococcus pneumoniae diseases in Chinese children: past, present and future. Vaccine 2008;26:4425-4433.
16 Introduction to 'Policy on the clinical use of antimicrobials' and management on antimicrobial stewardship. Ministry of Health of the People's Republic of China, 2012. at http://www.moh.gov.cn/mohyzs/s3586/201205/54646.shtml. (Accessed 20/02/2013)
17 Paskovaty A, Pflomm JM, Myke N, et al. A multidisciplinary approach to antimicrobial stewardship: Evolution into the 21st century. Int J Antimicrob Agents 2005;25:1-10.
18 Penm J, Moles R, Wang H, et al. Exploring Clinical Pharmacy Services in China: Application of the Basel Statements in Practice. Qual Health Res 2013;[Under review].
19 The Basel Statements on the future of hospital pharmacy. Am J Health Syst Pharm 2009;66:S61-66.
20 Sheikh AL. Basel Statements: Application in a tertiary care university hospital of Pakistan - What is the secret ingredient? . In: World Congress of Pharmacy and Pharmaceutical Sciences 2011 71st International Congress of FIP. Hyderabad, India; 2011.
21 Vaillancourt R. How the Basel Statements have been used in Uganda. In: World Congress of Pharmacy and Pharmaceutical Sciences 2011 71st International Congress of FIP. Hyderabad, India; 2011.
22 China health statistical yearbook 2012: Ministry of Health of the People's Republic of China, 2012.